Health Care Costs and Financing

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Despite a greater number of dental cavities, poor and minority children in the United States typically visit the dentist less often than other children. Three recent studies by Richard J. Manski, D.D.S., M.B.A., Ph.D., Senior Scholar at the Agency for Healthcare Research and Quality, and his colleagues examined the costs of dental care and the sources of payment for children and adults.

The first study finds that dental care for children accounts for about one-fourth of U.S. dental spending, with poor and minority children spending far less than higher income children. The second study reveals a shrinking disparity in dental care expenses between poor and higher income children and among minority and white children from 1987 to 1996. The third study shows a narrowing of the gap in dental expenditures between white and black adults from 1987 to 1996 and overall reduced dental expenditures among all adults.

About one-fourth of 1996 dental expenditures in the United States were for dental care for children. However, actual dental expenditures were 5.3 times as high for middle- and high-income children as for poor and near-poor children ($10.1 vs. $1.9 billion), despite Medicaid coverage for poor children. In fact, the high levels of reported out-of-pocket costs for Medicaid-eligible children suggest that Medicaid fails to meet families' needs for obtaining dental care, according to this study. The researchers used data from AHRQ's 1996 Medical Expenditure Panel Survey (MEPS), which included 6,595 children representing over 75 million noninstitutionalized U.S. children.

Results showed that disproportionately greater expenditures are made for white and higher income children than for minority and lower income children, despite the fact that white children have less dental disease. Expenditures for children's dental care totaled nearly $12 billion in 1996, for an average of $375 per child who obtained care. This is similar to the amount spent to treat childhood injuries or respiratory problems (including asthma).

Overall sources of payment for dental care were 47 percent out of pocket, 45 percent insurance, and 8 percent "other" (primarily Medicaid). Mean expenditures for poor and near-poor children were less than half of mean expenditures for higher income children. Poorer respondents reported lower mean out-of-pocket and private insurance payments for dental services than respondents from middle- and high-income families.

Actual dental expenditures for racial subgroups of children differed markedly from the proportion these subgroups represent in the U.S. child population. White children make up 66 percent of the child population, but they incurred 86 percent of actual expenditures. Black and Hispanic children each make up 17 percent of the population, but they consumed only about 6 percent and 8 percent of actual dental expenditures, respectively. Poor children (from families with gross annual 1996 incomes of less than $16,036 for a family of four) and "near-poor" children ($16,036 to $32,071 1996 income) each accounted for about 8 percent of dental care expenditures ($940-$980 million). Children from middle-income ($32,071-$48,108) and high-income ($48,108 or more) families accounted for 43 percent ($5.2 billion) and 41 percent ($4.9 billion) of 1996 dental care expenditures.

Wall, T.P., Brown, J., and Manski, R.J. (2002, April). "The funding of dental services among U.S. children 2 to 17 years old." Journal of the American Dental Association 133, pp. 474-482.

Based on a comparison of data from the 1987 National Medical Expenditure Survey (NMES) with data from the 1996 MEPS, these researchers found that overall dental expenditures among children 2 to 17 years of age fell nearly 14 percent from $578 in 1987 to $499 in 1996. Racial and ethnic disparities in dental expenditures were dramatically reduced during this time period. The absolute difference between white and black children fell from $315 in 1987 to $158 in 1996 and for non-Hispanic and Hispanic children from $245 to $72. Real dental expenditures tended to increase with the child's level of household income in both 1987 and 1996. However, the absolute difference between the highest and lowest income levels fell from $556 in 1987 to $230 in 1996.

Nevertheless, dental expenditures increased for poor children and decreased for higher income children (mostly due to a decrease in out-of-pocket payments). For example, in 1996, children below the Federal poverty level (FPL) who visited a dentist reported higher expenditures on average than children in the 100 to 200 percent of FPL income category ($404 vs. $276).

Overall out-of-pocket payments fell from 52 percent of the total payments for pediatric dental care to 38 percent. Contributions from private insurance and public funding held steady at 37 percent and 5 percent of the total, respectively, while the nonreimbursed category grew from 5 percent to 19 percent of the total.

Children in the two highest income levels received about 81 percent of the total dental care provided in 1996. Children in the lowest income group received 11 percent, but they received 24 percent of the unreimbursed care. Middle-class children did not need much restorative dentistry, mainly routine diagnostic and preventive services, and did not increase their expenditures between 1987 and 1996. Lower income children also showed a marked decrease in untreated dental caries, but they still needed more restorative care, even after the decrease. Children below the FPL were still less likely to visit a dentist in 1996 than upper income children.

Brown, L.J., Wall, T.P., and Manski, R.J. (2002, May). "The funding of dental services among U.S. adults aged 18 years and older." Journal of the American Dental Association 133, pp. 627- 635.

Dental expenditures among adults 18 years and older fell from $530 in 1987 to $467 in 1996, a decrease that may be related to a shift from restorative to diagnostic and preventive services. Disparities based on income, race, ethnicity, and sex, which were not large in 1987, were further reduced in 1996, according to this study comparing dental care expenditures detailed in the 1987 NMES and the 1996 MEPS. The study revealed a decrease in real dental expenditures during that time among whites from $538 to $467, which resulted in a narrowing of the gap between whites and blacks from $88 in 1987 to $30 in 1996. Hispanics reported a drop of $148 (25 percent) in real expenditures in 1996. In 1987, Hispanics reported higher average dental care expenditures than non-Hispanics, but in 1996, Hispanics reported lower expenditures.

Although expenditures tended to increase with the level of income in both survey years, the gap between the highest income group and the lowest decreased from $109 in 1987 to $56 in 1996.

For all adults, out-of-pocket payments decreased by 28 percent, from $301 in 1987 to $218 in 1996. This decrease was most pronounced in the below the FPL group, in which out-of-pocket payments decreased from $265 in 1987 to $157 in 1996. Out-of-pocket payments made up one-half of the total for those in the 100 to 200 percent of the FPL group, about 47 percent in the upper-income groups, and 36 percent in those below the FPL.

Private insurance accounted for 18 percent of total dental care expenditures for people with incomes below the FPL and rose to 41 percent among those in the highest income category. Public funding accounted for 21 percent of the total among those with incomes below the FPL and dropped to 4 percent of the total or less among those in high income categories.

Nonreimbursed care rose in every income category. It accounted for 24 percent of the total among those below the FPL, 16 percent among those with incomes 100 to 200 percent of the FPL, and 12 percent and 11 percent, respectively, among those in the middle- and upper-income categories. For those with an income below the FPL, nonreimbursed care amounted to $101 per patient and 24 percent of the total in 1996.